Video-assisted Thoracic Surgery

Video-assisted Thoracic Surgery* Manipulation Without Trocar in 112 Consecutive Procedures Hui-Ping Uu, M .D.; Pyng]ing Un, M.D. ; ]en-Ping Chang, M.D ., F.C.C.P. ; and Chau-Hsiung Chang, M .D., F.C .C .P. Since learning of the video-assisted thoracoscopic techniques in the treatment of thoracic diseases, we have encountered many problems and difficulties because of the limited trocar space and lack of suitable instrumentations. Since March 1992, we have found a simple and easier way to perform this procedure, that is, manipulating through the extended incisional wound without using a trocar. Endoscopic and conventional thoracic instruments are able

Today, surgical endoscopic technique is gaining popularity and is used in most fields of surgery. Under video-guide, this technique appeared to be possible in the treatment of selected patients. In the field of thoracic surgery, the recent explosion of interest in the thoracoscope with the combination of video-assisted devices also led to a newly developed technique-video-assisted thoracic surgery (VATS). Procedures that traditionally require open thoracotomy can now be done successfully using this new technique. However, only limited procedures could be performed with this traditional or video-assisted thoracoscopy. This is mainly because access and exposure are greatly restricted through the small trocar channel. Since March 1992, we tried alternative methods to manipulate this imaged thoracic procedure without using a trocar. Conventional thoracic instruments were used instead of endoscopic accessories. Instruments were introduced directly through the extended incisional channels instead of the trocar or the working channel of the thoracoscope. Table I lists the procedures we have accomplished using this "extended manipulating channel." This report summarizes our experience with the procedure. METHODS A 63-year-old man was referred for surgical management of recurrent spontaneous pneumothorax. Chest radiograph showed a <.~1llapsed left lung with persistent air leakage from the chest tube. Thoracoswpic ablaiion of the bullae was decided due to the impaired pulmonary function . However, preparations fi1r possible open thoramtomy were done also. Under adequate general anesthesia, a double-lumen endotracheal tube was inserted that allows selective <.~1llapse of the ipsilateral lung to maximize visualization of the whole pleural cavity. The patient was put in the lateral position. Steriliza*Fmm the Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, T:lipei, Taiwan, Republic of China. Manuscript re<:eived February 22, 1993; revision accepted May 24. Reprint requests: Dr. Uu , Chang Gung Mermnial Hospital, 199 Tun-Hwa North Road, Taipei, Taiwan, ROC

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to pass through the incisional channel freely and manipulate similarly to the technique used in open thoracotomy. All the patients had less postoperative pain, reduced operative time, and prompt return to employment. The technique is effective and is herein described. (Chest 1993; 104:1452-54) ..-V.-:A_T_S_=-vid_eo-_a-ss-i-st-ed-th_o_r_a-ct-.c-s-u-rg_e_ry--,1

lion and drapping were done in the usual manner. Atrocar, 11 mm in diameter, was introduced through a 2-cm incision into the left thoracic cavity (usually in the fifth intercostal space at the midaxillary line). The thoramscope was introduced through this trocar channel. With the aid of video-1V monitors, the operative field of the pleural cavity was clearly displayed on the monitor screen. The entire thoracic cavity was investigated with selective collapse or expansion of the ipsilateral lung. After localizing the lesion (usually the ruptured bulla), another two incisions were made close to this lesion. The incisions were extended transversely (usually 3 to 4 em), which allow passage of mnventional thoracic instruments into it. These extended incisional channels were used for insertion and manipulation of mnventional thoracic instruments. In this patient with spontaneous pneumothorax, the extended incisional channels were made in the third and fifth intercostal space at the anterior axillary line. A "C" clamp was introdu<.-ed through one of the manipulating channels and the ruptured bulla was grasped and excised . With the aid of the second manipulating channel, a long conventional needle holder with a suture was introduced into the chest cavity. The lung parenchyma was sutured similarly to the technique used in open thommtomy except that it was performed

Table 1- Vadeo-A.ssiBted Thoracic Procedures Without Trocar From March 1992 to December 1992 Procedure

No.

Bullous ablation Pleur.tl abrasion Thoracosmpic talc pleurodesis Parietal pleurectomy Pericardial window Mediastinal tumor Mediastinal biopsy Lung biopsy Exploration and biopsy for preoperative staging* Wedge resection Diaphragm eventrationt Decortication (empyema) Traumatic hemothorax Esophagectomy Esophagectomy + re<:onstruction Achalasia (myotomy) Lobectomy

35 6 7 5 13 6 3

5 2 15 1 3 2 1 6 l

*This patient presented with a multitude of pleural metastases. tThommK~lPY was done to rule out right diaphragmatic rupture caused hy chest trauma. Video-assisted Thoracic Surgery (Uu eta/)

under video-guide. Subsequent plenrodesis was a<:complished by introducing a small piece of scouring pad (usually tip cleaner or polyethylene template [Marlex]) through one of the manipulating channels. After completing the intrathoracic procedure, a chest tube was inserted through one of the incisions. The wounds were closed intermptedly with nonabsorbable sutures. Throughout the course, r most thoracic procedures. However, in patients receiving esophagectomy and re<.'Onstmction, a much longer postoperative hospital stay was required (7 to 16 days). There was no surgical morbidity or mortality in the follow-up period between 3 and 11 months, with an average of 7.5 months. During this interval, no untoward incident related to the pnx:edure was observed, and most patie nts resumed their preoperative level of activity within 3 weeks. DISCUSSION

With the improvement of video optics and instrumentations, endoscopic procedures have rapidly expanded in recent years. In the field of thoracic surgery, such procedures are also gaining in popularity and acceptance from chest surgeons. •-a Wakabayashi 4 has reported the excellent result of spontaneous pneumothorax by using thoracoscopic techniques. Landreneau et al2 also reported the usefulness of thoracoscopic YAG laser in pulmonary resection. With the rapidly expanding and improving of visualization, thoracoscopy was employed not only to determine the chest lesions but was also used in the treatment of various thoracic diseases. s-w This was found to be particularly helpful in poor-risk patients who can tolerate only limited interruption of ventilatory mechanics. However, despite the development of VATS , procedures were still restricted due to limited space of trocar for manipulation. Lack of suitable thoracoscopic instrumentation also precludes the procedures. The trocar method makes the manipulation difficult and time-consuming within the chest cavity. Access and exposure were markedly reduced through these restricted trocar channels. Besides, manipulation of endoscopic instruments through its working ch~Imel Wll.S also greatly limited. All these disadvantages make the procedures complicated and operative time prolonged . Since March 1992, we have used an easier way to manipulate the procedures, that is through the extended incision channel without using a trocar. We found it very easy to perform the procedure and exposure was greatly improved. The endoscopic instruments can easily manipulate within the channel, and conventional thoracic instruments such as lung forceps, needle holders, and different types of staplers

can all easily pass through the extended incisional hole and manipulate freely just as in the field of open thoracotomy. The ideal of these, which we call the "extended manipulating channel," seems attractive and we always create it before starting the procedure. All the thoracoscopic procedures, including removal of mediastinal tumors and lung resection, can be performed using this technique. We found it to be a simple, easier procedure and it has better results. Operative time was greatly reduced. Active bleeders could be controlled immediately with vascular clamps through these extended incisional wounds. The applicability of this combination (video-assisted thoracoscopy and conventional thoracic instruments) has greatly extended the list of indications. A broad spectrum of surgical procedures, including removal of almost all of the benign thoracic lesions, can be performed using this method. Procedures such as excision of peripheral lung nodules, lung biopsies, decortication of pleura, mediastinal tumor, bullous diseases, pericardia} window, lobectomy, and even esophagectomy can be performed. We believe that as skills and experiences increase, radical lymph node dissection concomitant with lung resection (lobectomy or pneumonectomy) will be technically feasible in patients with thoracic malignancy, especially in aged and poor-risk patients. However, one should not allow the desirability of minimally invasive surgery to result in an operation that may compromise the long-term survival. The limitations of VATS procedure in lung cancer surgery was the lack of ability to feel the lung or take biopsy specimens of various stations of lymph nodes, which is standard practice for a complete lung cancer operation. If the procedure cannot be completely and safely performed, one should always immediately convert to conventional thoracotomy. In our series, there were six patients who had conversion to open thoracotomy because of intolerable one-lung ventilation in two patients and severe pleural adhesion in the other four patients. In addition, we would like to recommend that the procedures should be performed only by thoracic surgeons who already have expertise in both videoscopic and general thoracic surgery. Reduced operative time, less postoperative pain, less interference with ventilatory mechanics, no intensive service needed, less cost, and prompt return to preoperative level of activity and employment are all benefits and advantages that will definitely lead this type of procedure into gaining an important place in the future trend of thoracic surgery. We believe that, in the near future , most of the thoracic procedures will be accomplished through this new evolutional technique- VATS. REFERENCES

1 Vanderschue ren RC. The role of thoracoscopy in the evaluation and management of pneumothorax. Lung 1990; 168(suppl): 1122CHEST I 104 I 5 I NOVEMBER, 1993

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25 2 Landreneau RJ, Herlan DB, Johnson JA, Boley TM, Nawarawoog W. Ferson PF. ~ neodymiun: yttrium-aluminum garnet lase~assisted pulmonary resection. Ann 11lorac Surg

1991; 52:1176-78 3 Walcabayashi A, Brenner M, Wilson AF, 'llldir Y, Berns M. 11loraoosoopic treatment of spontaneous pneumothorax using carbon dioxide laser. Ann 11lorac Surg 1990; 50:786-90 4 Walcabayashi A. 11loraoosoopic ablation of bleeds In the treatment of recurrent or persistent spontaneous pneumothorax. Ann Thorac Surg 1989; 48:651-53 5 Torre M, Belloni P. NCI:YAG laser pleurodesis through thoracoscopy: new curative therapy In spontaneous pneumothorax. Ann Thorac Surg 199; 47:887-89

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6 Oakes DD, Sherdc TP, Brodsky JB, Mark JB. Therapeutic thoracoscopy. JThorac Cardiovasc Surg 1984; 87:2169-73 7 Page RD, Idli-ey RR, Donnelly RJ. Thoraooscopy: a review of 121 consecutive surgical procedures. Ann 11lorac Surg 1989;

48:66-8

8 Singh SV. The surgical treatment of spontaneous pneumothorax by parietal pleurectomy. Scand J 11lorac Cardiovasc Surg 1982;

16:75-80

9 Lewis RJ, Sisler GE, Caccavale RJ. Imaged thoracic lobectomy: should It be done? Ann Thorac Surg 1992; 54:~ 10 Landreneau RJ, Dowling RD, Castillo WM, Ferson PF. 11loracosoopic resection of an anterior mediastinal tumor. Ann 11lorac Surg 1992; 54:142-44